DISCUSSION Demographic and Housing Status of the Respondents. Out of the 3456 respondents to the BES survey in TTS district, 93 TB cases were found and this was approximately 2.68%. In Bandung out of 5269 respondents, 54 (1.02%) TB cases were found. This figure shows that in both districts TB prevalence is higher than the figure from a national survey conducted in 1999 which reported the prevalence level at 0.9% (Bandung district health office, 2000). TTS had a higher number of cases of TB than Bandung.

TTS represents a less developed area where health facilities are not as accesible as in Bandung with almost 97% of respondents on an average income of less than Rp. 300,000/month (US$ 360 per year). It may be reasonable to assume that health has not yet become a high priority in this district, since a majority of their income still has to be spent on basic such as food and shelter. This finding is in line with other research that shows that tuberculosis is still regarded as a disease of the low socioeconomic status (Rieder, 1999, Sawert, 2000).

Tuberculosis Prevalence and Characteristic of the Respondents In Bandung the majority of cases, 36 (67% of respondents) were males while in TTS the majority of cases were females with 58 or 62.4% of the respondents. The age distribution in both districts was similar. The difference in the number of cases by gender might not be recognized solely as the result of the respondent characteristic. This conflicting evidence is in line with previous studies which have shown that in some areas the risk of disease varies between males and females. Specifically Comstock and O’Brien (1998), supported by Iseman (2000), showed that in the United States the incidence of tuberculosis infections is lower among females.

Even though the population in TTS is predominantly younger, cases are occurring in the older age groups. This probably can be attributed to the success of immunization program. Only a very small number of cases were present in the group less than 15 years old. This is a good encouragement that indicating that there is less transmission in this age group, assuming that accurate diagnosis have been made. In TTS district more females suffered TB than males and this might reflect the mode of the transmission since females are more likely to stay longer in the house with the limited ventilation and in crowded condition.

Comstock and O’Brien (1998) stated that in high risk populations there is a peak of infection in infancy followed by a second peak in young adulthood and sometimes a third peak in old age. The reason for the increased incidence among young adult is not known even though in some countries these can be attributable to the spread of HIV-AIDS. This second peak is important to be considered for the prevention program because it might become a crucial stage. The first peak reflects the effect of a new and recent infection and might be attributed to the weaknesses of infant’s immune system. This problem has already taken into account by the immunization program. The third peak in old age is usually attributed to the relapse of the disease.

Marital status shows an important association with the prevalence of TB. Married person have an increased risk of contracting TB of 3 times in Bandung and 5 times in TTS compared to unmarried one. As the numbers of divorced and widowed respondents were too small to consider separately for analysis purposes hence, they were combined with single respondents. For this particular finding, it is suggested that close contact between married couple might be important as a source of transmission. It is reasonable to also consider that people tend to be treated by the closest family member that is husband or wife when they were sick.

The results of this study shows that most TB cases in TTS were in people who had an income level of less or equal to Rp.300,000. In Bandung it was the other way around, with TB in people with the income level more than Rp. 300,000. Sawert (2001) has shown that the socio-economic distribution of tuberculosis patients does not differ significantly from that found in the general population. The finding from this study shows that the distribution of TB is attributable to the differences in respondents characteristic in both districts.

Tuberculosis Cases and Housing The variables used to define ventilation were the number of bedrooms with window and small apertures while the variables used to define crowding are household density and bedroom density. In this study, TB prevalence in the TTS District showed significant association with household density, bedroom with window and type of wall. Household density or level of crowding was measured as TB mostly affects people living in a crowded condition. Yassi (2001); WHO (1997a); Baum (1997) and McMichael (1993) stressed the importance of overcrowding facilitating the transmission of diseases including tuberculosis. Conditions

Ventilation as represented by bedrooms with windows also showed a significant association in TTS but not in Bandung. This result corresponds with the work of Kustijadi (2001) who found that the risk of getting TB was 8 times greater for houses that had less than 10% ventilation, compared to situation where ventilation is more than 10% of floor areas. Ventilation is very important in introducing fresh air into a house because there is a need to dilute the concentration of potential infective particles, thereby lowering the likelihood of transmission.

Windowless houses might prolong the lifecycle of microorganism because they create optimum conditions for them. Kustijadi (2001) found that children under five have the risk of having tuberculin positive test if they live in a house with more than 70% humidity. This finding may indicate that humidity depends also on the intensity of the sunlight and the amount of ventilation in the room. Humidity also depends on the flow of air in the room which can dilute the concentration of the bacteria. A traditional way of decreasing the humidity entails putting charcoal in the humid place. Charcoal should be changed routinely to ensure that it can still absorb moisture.

Limitation of the study Study design This was a cross-sectional study which described the prevalence of TB cases and the environmental conditions at one point of time. There are doubt as to whether the environmental conditions came before or after contracting TB. A longitudinal study would solve this problem. However prevalence data also includes information on survival time. This may be affected by the availability of treatment and not be related to causation.

CONCLUSIONS AND RECOMMENDATIONS

Conclusions The key conclusions derived from this study are: 1. Tuberculosis is one of the important diseases in TTS and Bandung District and attention to controlling this disease should become the priority. 2. In both district TB cases were found in people with low income level and poor level of education. This shows that people with lower socio-economic status are more susceptible to disease. 3. Crowding and ventilation were the factors statistically associated with TB cases in TTS and they need to be taken into account in health promotion programs as well as in programs aimed at improving living and health conditions.

Recommendations To break the cycle of TB transmission it is recommended that: 1. The findings of this study being used for a base in developing a strategy for promoting a “better housing project” in each district. 2. Interventions aimed at reducing the number of unhealthy houses been supported. Simple and affordable methods of improving the quality of the domestic environment such as the use of windows to improve ventilation and glass roof tiles to ensure the input of sunlight into the house and the use of charcoal to decrease humidity been promoted.

Recommendations (cont) To break the cycle of TB transmission it is recommended that: 3. Further studies be undertaken to seek clearer explanations regarding the domestic environmental factors and social-economic factors to prevent the spread of TB in urban and rural areas with similar environmental conditions and demographic characteristics to Bandung and TTS.

REFERENCES